1. Introduction

Sub-Saharan Africa remains the region most heavily affected by HIV, and accounted for 68% of all people living with the virus and for 72% of AIDS deaths in 2009[1]. The HIV/AIDS epidemic in Ethiopia continues to pose a threat to the lives of people. It is estimated that 977,394 people live with the virus resulting in 71,902 HIV related deaths in 2007. The national prevalence of HIV in 2007 is estimated to be 2.1%[2].

Provision of Antiretroviral Therapy (ART) has reduced mortality and also improved the quality of life of people living with HIV and AIDS (PLWHA)[3]. In 2009 alone, 1.2 million people received ART for the first time worldwide[1]. By the end of 2009, there were more than five million people on ART in middle and low income countries. In Sub-Saharan Africa, nearly 37% of people eligible for treatment were able to access ART in 2009[1]. In Ethiopia provision of ART was started in 2003. At the end of June 2008, there were only 110,611 patients (75%) who were alive and on ART out of the 150,136 patients who had been started ART since 2003[4].

Despite this success, poor adherence to ART and defaulting from ART are two major challenges in resource- limited settings[5]. Defaulting reduces the immunological benefit of ART and increases AIDS related morbidity, mortality and hospitalizations[6]. Poor adherence and defaulting from ART treatment increase the risk of drug resistance and treatment failure[5, 7- 8]. A systematic review of 33 patient cohorts from 13 African countries reported that only between 46% and 85% of patients remained in care at 2 years[9]. Studies done in Ethiopia and South Africa had reported, the overall rate of defaulting treatment were 13.6% and 12.8/100 person years respectively[5, 10].

Different studies reported that defaulting from ART are influenced by distance from facility[10--16], transportation cost[12, 14, 16], drug abuse[10, 17], being bed redden[10], having HIV negative partner[10], depression[18], stigma[16, 18-20], CD4 count[16], food insecurity[21], adherence support services and food rations at HIV care clinics[22].

Previous studies conducted in Ethiopia addressed adherence to ART and associated factors. However, the broader aspects of defaulter and associated factors were not well studied in Ethiopia especially in the zonal hospital. There is only one study that is conducted on this issue and it was conducted in tertiary hospital[10]. Thus this is the first by its kind in zonal hospital in Ethiopia. Besides, the defaulter rate in Nekemte hospital was 21.7% which was the highest (from 2837 ever started 616 patients were defaulters) when compared with the study on Jimma specialized hospital(13.6%)[10]. Therefore the aim of this study was to assess determinants of defaulting from antiretroviral therapy in Nekemte Hospital, West Ethiopia.

2. Methods and Materials

A case control study was conducted in Nekemte Hospital from March 2011 to April 2011. Nekemte town is located 331 Kilometers West of Addis Ababa, the capital city of Ethiopia.

Cases were ART treatment defaulters. ART treatment defaulters in this study are defined as an HIV positive patient who had been on ART treatment and missed two or more monthly clinical appointments[10], and age 15 years and above. Controls were individuals who had been on ART at least for one year and were rated as excellent adherers by the providers[10] and age 15 years and above. For each case, a control that was enrolled in the same month was selected. If more than one control enrolled in the same month, the closest date of enrolment determined selection. Patients attend the ART clinic each month to refill the ART drugs.

The sample size was calculated using Epi-info version 6.0.4 software. As estimated from study done in Jimma, proportion of patients living far (distance) from the facility among the cases and controls being 44.1% and 26.0% respectively[10]. At 95% CI and 80% power and case to control 1:1, the total sample size required were 238 (119 cases and 119 controls). The hospital record was used as sampling frame. An electronic pharmacy record was used to generate lists of patients who have failed to pick up medication (defaulters). From lists of defaulter, 119 patients (cases) were randomly selected from the eligible.

Using semi-structured questionnaires (a case note extraction), socio-demographic and behavioral information, and clinical factors that could potentially be associated with defaulting (which were recorded at the time treatment started) were retrieved from patient records and cards. The patient card and other forms included questions on socio-demographic information, past medical status, mental health status, and concerns for adherence. The retrieval was conducted by a data clerk in the hospital. Data were also gathered on telephone calls through their addresses recorded at the beginning of ART where possible. In occasions where telephone interview was not feasible five trained peer counselors were used to trace and interview defaulters at home. The interview was conducted at hospital for controls during follow-up visit. The questionnaire was first prepared in English language, then translated to a local language and retranslated to English to check for consistency. Data collectors and supervisors were trained for two day on the methods, objectives and data collection tool before the data collection.

Data were entered, processed and analyzed using SPSS software version 16. Data analysis was started by describing each variables involved. Bivariate analysis was done for each explanatory variable separately; to identify those associated to ART treatment defaulting. Variables with p-value less than 0.20 in the bivariate analysis were considered as candidate to be entered in the multivariable logistic regression model. The logistic regression model was fitted by using back ward elimination technique. Log likelihood ratio test was used to assess the goodness of fitness of the final model.

The ethical clearance was obtained from Jimma University. Written informed consent was also obtained from each respondent.

3. Result

Table 1. Sociodemographic characteristics of study participants, Nekemte Hospital, 2011

A total of 236 individuals were interviewed, having the response rate of 99.2%. From the total of study participants, about a two-fifth of both cases and control were male (42.4% for case and 40.7% for control group). Fifty three (44.9%) of case and 60(50.8%) of control were in age group of 25-34 years. Patients who live in the town were 57(48.3%) and 87(73.7%) of cases and controls respectively. Concerning educational status of participants, 28(23.7%) of case and 8(6.8%) of control group were illiterate. Forty seven (39.8%) of case and 7(5.9%) of control had no monthly income and were dependent on others (table1).

Table 2. Bivariate analysis of factors related to ART treatment defaulting, Nekemte Hospital, 2011

Table 2. continue ….

Table 3. Independent determinants of ART treatment defaulting in Nekemte hospital, 2011

Among the study participants, 10(8.5%) of cases and 6(5.1%) of controls complained the side effect of ART drugs. Patients that complained the fear of stigma were 44(37.3%) of cases and 8(6.8%) of controls. Twenty one (17.8%) of case and 6(5.1%) of controls were seeking help from traditional healers/holly water. Patients who were on TB treatment among cases and controls were 24(20.3%) and 31(26.3%) respectively.

At ART enrollment, 17(14.4%) of cases and 10(8.5%) of controls were smokers, 35(39.7%) of cases and 17(14.4%) of controls had CD4 count 50 and less. HIV status of partners of 46(39.0%) of cases and 32(27.1%) of controls were unknown/ not tested. All characteristics of patients at ART enrollment considered in this study were significantly associated with defaulting from ART treatment.

In bivariate analysis many factors were associated with ART defaulting (Table 2).

In the multiple logistic-regression model, only 5 factors were found to be independently associated with ART defaulting: living outside the town, dependent for source of food, mental illness not at ease, and having an HIV negative partner (or not tested/unknown HIV status), and complain stigma.

In this particular study, patients living far from the facility (out of the town) were more likely to default the treatment than patients living in the town (AOR=4.1; 95%CI 1.86 to 9.42). Dependent patients for source of food were more likely to default from ART treatment compared to independent patients for food[AOR=13.9; 95%CI 4.23 to 45.99]. Those patients with mental status not at ease were 4.19 times more likely to default from ART treatment compared to those with normal[AOR=4.7; 95%CI 1.65 to 13.35]. Compared to those whose partners were HIV positive, the risk of defaulting from ART treatments were 5.14 times higher among patients whose partners were HIV negative[AOR=5.1; 95%CI 1.59 to 16.63], and 2.83 times higher among patients whose partners HIV status were unknown or not tested[AOR=2.8; 95%CI 1.23 to 6.50]. The risk of defaulting from ART treatments among patients that fear stigma were higher compared to those without fear of stigma[AOR=8.3; 95%CI 2.88 to 23.83] (Table 3).

4. Discussion

This study intended to identify the determinants of defaulting from ART treatment. The study used analytic case control design. However, it might have some limitation such as: first, recall bias on some risk factors like drug side effect, toxicity and stigma. Second, distance from health facility was assessed by living in Nekemte town or outside the town, it would have been better in kilometers or hours it take to reach the facility. Distance in Kms or hrs were tried to obtain and majority of participants living outside the town did not respond. So the distance in this study should be interpreted cautiously. Third, using telephone interview for some defaulters may reduce the quality of information as compared to controls. This was used only for very few individual thus may not harm the validity of the study.

This study have identified important determinant factors of ART treatment defaulting. In this study living out of the town or far from the facility was significantly associated with ART treatment defaulting. Similar finding was reported by study done in Ethiopia, Kenya, Uganda and South Africa[10-13]. Distance to clinic and transportation are main factors for defaulting from care in a wide variety of settings developing countries[12-16]. This might be because people need to take time off from work to travel great distances to clinics and wait for the service all day. This may discourage patients to come back for ART treatment clinical appointments.

Among the socio-economic, patients who had no source of food (economically poor) and living dependently (on relatives, NGO, Government, etc) were 14 times more likely to default compared to patients who live independently. In Jimma zone of Ethiopia, 17.6% of patients who defaulted reported lack of food as a reason for absence from clinic[10].

Patients mental status were significantly associated with ART treatment defaulting. This had been reported by study done in Ethiopia and Nigeria[10, 18]. Depression and emotional adjustment to the HIV infections have been observed as other possible reasons why patients default from ART use[18].

Patients with a fear of stigma or Stigmatized patients were 8.3 times more likely to default than not stigmatized (had no fear of stigma). Similarly finding has been reported by study done in Botswana and Nigeria[18, 19]. Stigma is daily issues facing people infected with HIV/AIDS especially in developing countries. Stigma was mentioned as one factor that constrained patients on antiretroviral therapy from sticking to agreed-to treatment plans. The issue of stigma has been a barrier to people living with AIDS disclosing their status and getting access to available support and care services[18].

Patient whose partner was an HIV-negative partner or unknown HIV status was more likely to default from treatment. Similar finding had been reported by study done in Ethiopia[10]. These may be HIV-infected individuals who had an HIV-positive partner who provided support and encouragement compared to those who had HIV-negative or unknown HIV status partner[10].

5. Conclusions

In Inclusion, PLWH who were living out of the town or far from the facility, whose partner’s HIV status was negative ot unknown, who were stigmatized and mental ill had a higher chance of defaulting from ART treatment. Besides, those who were dependent on other foor food were more likely to defasult from the treatment. So it is recommended to make ART treatment available patients at the village. The staff should advise the patients and make them to bring their partner for HIV test. Linking patients to local social support or facilitating income generating activities for PLWHA to increase their income should be a priority issue. Effort should be made to decrease stigma. Intensifying counseling of patients before initiating and during treatment is importance so that PLWHA can adjust both psychologically and emotionally to the disease. Addressing stigma on an individual level and community level should be considered.

ACKNOWLEDGEMENTS

We would also like to thank Jimma University for its financial support. We are very grateful to all supervisors, data collectors and study participants who took part in the study.

Competing of Interests

The authors declare that they have no competing interests.